Schizophrenia Research 88 (2006) 63 – 72

www.elsevier.com/locate/schres

A model of anticholinergic activity of atypical

antipsychotic medications
Marci L. Chew a,b , Benoit H. Mulsant b,c,d,⁎, Bruce G. Pollock b,c,d,e , Mark E. Lehman f ,
Andrew Greenspan g , Margaret A. Kirshner b , Robert R. Bies a,b ,
Shitij Kapur c,d , Georges Gharabawi h
a
Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
b
Geriatric Psychopharmacology Laboratory, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
c
Geriatric Mental Health Program, Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario, Canada M6J 1H4
d
Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada M5T 1R8
e
The Rotman Research Institute, Toronto, Canada
f
Ortho McNeil-Janssen Scientific Affairs, LLC, 135 Calumet Court, Crestview Hills, KY 41017, USA
g
Johnson&Johnson Pharmaceutical Research and Development, 1125 Trenton-Harbourton Road, Titusville, NJ 08530, USA
h
Medical Affairs, Janssen Pharmaceutica, Inc, 1125 Trenton-Harbourton Road, Titusville, NJ 08530, USA
Received 24 March 2006; received in revised form 5 July 2006; accepted 6 July 2006
Available online 22 August 2006

Abstract

Background: Atypical antipsychotics clozapine, olanzapine, and quetiapine have significant affinity for the muscarinic receptors in
vitro, while aripiprazole, risperidone, and ziprasidone do not. Dissimilarity in binding profiles may contribute to the reported
differences in the anticholinergic effects of these antipsychotics. However, it is difficult with the available data to predict the
likelihood of anticholinergic effects occurring with various doses of an atypical antipsychotic.
Methods: We developed a model to assess the potential anticholinergic activity (AA) of atypical antipsychotics at therapeutic doses.
A radioreceptor assay was used to measure in vitro AA at 6 clinically relevant concentrations of aripiprazole, clozapine,
olanzapine, quetiapine, risperidone, and ziprasidone. Using published pharmacokinetic data, in combination with the measured in
vitro AA, dose–AA curves were generated.
Results: Clozapine, and to a lesser extent olanzapine and quetiapine showed dose-dependent increases in AA. At therapeutic doses,
the AA (in pmol/mL of atropine equivalents) was estimated to range from 27–250, 1–15, and 0–5.4 pmol/mL for clozapine,
olanzapine, and quetiapine, respectively. Aripiprazole, risperidone, and ziprasidone did not demonstrate AA at any of the
concentrations studied.
Conclusions: Therapeutic doses of clozapine, olanzapine, and, to a lesser extent, quetiapine are associated with clinically relevant AA.
© 2006 Elsevier B.V. All rights reserved.

Keywords: Psychopharmacology; Atypical antipsychotic; Anticholinergic; Muscarinic receptor; Schizophrenia; Cognition

⁎ Corresponding author. CAMH, #3011, 1001 Queen Street West,

1. Introduction
Toronto, Ontario, Canada M6J 1H4. Tel.: +1 416 535 8501x3656; fax:
+1 416 583 1307. Over the past decade, several atypical antipsychotics
E-mail address: benoit_mulsant@camh.net (B.H. Mulsant). have become widely used (Lieberman et al., 2005). These
0920-9964/$ - see front matter © 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2006.07.011
64 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72

Table 1
Binding of atypical antipsychotics at dopamine 2 (D2) and muscarinic receptors (MR) a
Medication D2 b MR b D2/MR MR1 c MR2 c MR3 c MR4 c MR5 c
Aripiprazole 0.45 d N10, 000 d b0.0001 6780 e 3510 e 4680 e 1520 e 2330 e
Clozapine 210 9 23.3 1.4 10 7 6 5
Olanzapine 20 36 0.56 2.5 18 13 10 6
Quetiapine 770 1400 0.55 120 630 1320 660 2990
Risperidone 3.77 34, 000 0.0001 N10,000 N10,000 N10,000 N10,000 N10,000
Ziprasidone 2.6 2440 0.001 5100 f N3000 N1300 N1600 N1600
a
Values reported are either equilibrium dissociation (Kd) or inhibitory (Ki) constants in nanomolar (nM) units. Both constants reflect affinity;
smaller values indicate greater receptor affinity.
b
Used human brain (caudate nucleus) homogenate in buffer with [3H]-spiperone for D2 and [3H]-QNB for MRs (Richelson and Souder, 2000).
c
Used clonal cell membranes in buffer with [3H] N-methylscopolamine (Bymaster et al., 1996; Bymaster and Falcone, 2000; Bymaster et al.,
2003a).
d
Specific details regarding the source of receptors and the radioligands used were not provided (Briston-Myers Squibb, data on file; Goodnick and
Jerry, 2002).
e
Used clonal cell membranes in buffer with [3H]-QNB (Shapiro et al., 2003).
f
Used clonal cell membranes with [3H] N-methylscopolamine (Schmidt et al., 2001). Please note, Bymaster and colleagues (2003a) reported the
binding affinity of ziprasidone at MR1 to be 300 nM.

atypical antipsychotics are hypothesized to improve
psychotic symptoms through similar mechanisms. How-
ever, each of these medications has a unique pharmaco-
logical profile and has been associated with differing
frequencies of adverse effects (Lieberman et al., 2005).
From a pharmacological perspective, one important dif-
ference between the atypical antipsychotics is the vari-
ation in binding to muscarinic receptors.
Muscarinic receptors are thought to be involved in
multiple central processes including body temperature,
movement, analgesia, arousal, attention, and cognition.
To date, five specific muscarinic receptor subtypes have
been identified (Bonner et al., 1987; Caulfield, 1993;
Bymaster et al., 2003a; Felder et al., 2001). All 5 sub-
types are present in the central nervous system (CNS),
with a predominance of M1, M2, and M4 (Flynn et al.,
1995).
Specific muscarinic receptor substrates and knock-
out mice have become available to study the role of
individual muscarinic receptor subtypes only during the
past several years. Recent studies have suggested that
M1, M2, and M4 are important for learning and memory
(Veroff et al., 1998; Hamilton et al., 2001; Matsui et al.,
2004; Jerusalinsky et al., 1998; Lachowicz et al., 2001;
Bymaster et al., 2003b). M1 and M4 are also thought to
play a role in motor control (Bymaster et al., 2003b;
Gomeza et al., 1999) and pharmacotherapy of psychoses
(e.g., muscarinic receptor agonists have antipsychotic
activity) (Felder et al., 2001; Mirza et al., 2003; Gomeza
et al., 1999).
Early pharmacological data have documented that
clozapine, olanzapine, and quetiapine have significant
affinity at muscarinic receptors, relative to their affinity at
dopamine 2 (D2) receptors (Table 1). Conversely, in vitro
binding at muscarinic receptors is negligible for aripipra-
zole, risperidone or ziprasidone. These in vitro differences
may have clinical significance. Mulsant and colleagues
(Mulsant et al., 2004) reported elevated anticholinergic
activity (AA) in patients with dementia following ini-
tiation of treatment with olanzapine. Similarly, Tracy and
colleagues (Tracy et al., 2001) found that schizophrenic
patients taking clozapine or olanzapine had higher AA
than those receiving risperidone. Higher AA was asso-
ciated with impairment in performance, verbal learning
and executive control.
In addition, anticholinergic medications may reduce
the effectiveness of antipsychotic medications (Johnstone
et al., 1983). In one small cross-over study, increases in
muscarinic receptor binding in the striatum with a change
in olanzapine dose from 5 to 20 mg was correlated to an
increase in negative symptoms in persons with schizo-
phrenia (Raedler et al., 2000). On the other hand, mus-
carinic receptor blockade may protect an individual from
developing extrapyramidal symptoms associated with
antipsychotic use (Tune and Coyle, 1980, 1981; Richel-
son, 1999). Thus, patients receiving an antipsychotic
medication with anticholinergic properties may have an
improved clinical outcome by virtue of enhanced tole-
rability and compliance (Tandon and Jibson, 2002).
Thus far, the comparisons of the anticholinergic po-
tential of the atypical antipsychotics have been based
mostly on their equilibrium dissociation (Kd) or inhibitory
(Ki) constants for the muscarinic receptors. However, it is
difficult to predict the in vivo anticholinergic effects of
various doses of a given medication based on Kd or Ki
alone. Data obtained using Single Photon Emission To-
mography (SPECT) imaging has provided preliminary
evidence of the relationship between dose and central
 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72 65

muscarinic receptor binding (Lavalaye et al., 2001; Table 2

Raedler et al., 2000, 2003). Both clozapine and olanzapine Typical dose and concentration ranges of atypical antipsychoticsa
showed dose-dependent increases in muscarinic receptor Drug Typical Typical Typical Concentrations
occupancy in multiple brain regions of schizophrenic pa- dose dose concentration tested for in
range in range in ranges vitro AA
tients including the thalamus and frontal and temporal adults elderly (ng/mL) (ng/mL)
cortices (Raedler et al., 2000, 2003). Patients treated with (mg/day) (mg/day)
risperidone showed a small increase in muscarinic receptor
Aripiprazole 10–30 10–30 0–1000 10, 50, 100,
occupancy in the striatum, although these findings may 250, 500, 1000
have been an artefact of comparing occupancy with healthy Clozapine 300–900 25–400 0–1500 10, 50, 100,
controls (Lavalaye et al., 2001). Although informative, the 250, 500,
above studies had small sample sizes with a limited number 1000, 1500
Olanzapine 7.5–30.0 5–15 0–150 10, 25, 50,
of doses examined.
100, 150, 250
A radioreceptor assay (RRA) is available to quantify a Quetiapine 200–800 50–300 0–1500 50, 200, 500,
person's overall anticholinergic burden caused by the 1000, 1500,
cumulative effects of all drugs, metabolites, and poten- 2500
tially endogenous substances—referred to as anticholin- Risperidone 1.5–6.0 0.5–3.5 0–50 10, 50, 100,
250, 500, 1000
ergic activity (AA) (Chew et al., 2005; Mulsant et al.,
Ziprasidone 40–160 40–160 0–750 10, 50, 100,
2003; Tune and Coyle, 1980). This in vitro assay examines 250, 500, 1000
the amount of displacement of the muscarinic receptor a
Alexopoulos et al., 2004; Aripiprazole, package insert; Barak et al.,
antagonist tritiated quinuclidinyl benzilate (3H-QNB) 1999; Clozapine, package insert; Gex-Fabry et al., 2003; Huang et al.,
caused by compounds present in an individual's serum 2002; Jaskiw et al., 2004; Lieberman et al., 2005; Mallikaarjun et al.,
(or plasma). 3H-QNB is a specific antagonist with high 2004; Mauri et al., 2001; Olanzapine, package insert; Quetiapine,
affinity for all muscarinic receptor subtypes (Bolden et al., package insert; Risperidone, package insert; Rostami-Hodjegan et al.,
2004; Wilner et al., 2000; Ziprasidone, package insert.
1992). Peripheral AA has been correlated with serum
levels of anticholinergic medications (Aaltonen et al.,
1985; Iisalo and Aaltonen, 1984; Tune and Coyle, 1981) were purchased in pill form from our hospital pharmacy.
as well as AA in cerebral spinal fluid (Miller et al., 1988). Stock concentration of all medications was 1 mg/mL.
We used such a RRA to develop an in vitro model to Aripiprazole/clozapine and olanzapine/quetiapine were
assess the potential in vivo AA of various dosages of six completely dissolved in methanol and 0.1 N HCl, respect-
atypical antipsychotics. The assay we utilized employs ively. Drugs purchased in pill form were placed in 0.1 N
similar methods used previously to determine the Ki or Kd HCl, vortexed, and placed on an Eberbach shaker on high
of medications with the most relevant differences being for 30 min and then centrifuged at 600×g for 5 min, at 4 °C
the use of human serum in each sample, an atropine to remove excipients.
standard curve to allow comparisons between medica-
tions, and focusing on clinically relevant concentrations. 2.2. Procedure
The concentrations of atypical antipsychotics that we
examined were based on published reports of typical In vitro AA of the antipsychotics was measured using
serum or plasma drug levels (Table 2). Subsequently, to a modified version of a competitive radioreceptor binding
make these data more useful to clinicians, we used pub- assay previously described (Chew et al., 2005; Mulsant et
lished pharmacokinetic data to translate the concentra- al., 2003; Tune and Coyle, 1980). In brief, 3H-QNB
tion–AA relationship into an estimated dose–AA (PerkinElmer Life Sciences), was used as the radioligand
relationship. We propose that clinicians can use this and atropine (Sigma-Aldrich) was used for the standard
model to estimate the relative anticholinergic risks and curve. The assay was conducted on ice and all solutions
benefits of a given dose of an atypical antipsychotic. used were at 4 °C. For the standard curve samples, a
homogenized mixture of rat (Sprague–Dawley males,
2. Methods approximately 200–225 g) forebrain and striatum were
added to a mixture of varying concentrations of atropine
2.1. Materials (0.1 nM–10 nM), drug-free human off-the-clot serum
(Scantibodies), and 50 mM sodium phosphate buffer, pH
Aripiprazole, olanzapine and quetiapine fumarate were 7.7. For medication samples, an antipsychotic was added
purchased from Sequoia Chemicals and clozapine from in place of atropine (Table 2). Following the addition of
Sigma-Aldrich, risperidone and ziprasidone hydrochloride muscarinic receptors, samples were vortexed and
66 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72

Table 3
Estimated Cmax values, based on total daily doses of clozapine
Clozapine Cmax (ng/mL)
Dose Adult male Adult female Elderly male Elderly female
(mg/day)
50 95 112 107 139
100 164 190 203 234
200 302 345 374 428
300 388 474 481 588
400 500 586 621 728
600 690 819 855 1016
800 862 1035 1069 1283

given Cmax. These doses and AAs were then plotted to

Fig. 1. Atropine standard curve. An atropine standard curve was run on
each assay day. The in vitro anticholinergic activity (AA) of a drug was
based on the decrease in 3H-QNB muscarinic receptor binding in the
presence of this drug. Change in radioligand binding with a drug was
related to the amount of atropine needed to displace the same amount
of 3H-QNB.
generate dose–AA curves.
The following pharmacokinetic principles were used
to estimate the average Cmax at each dose for clozapine,
olanzapine, and quetiapine:

(1) Clozapine: The average clozapine Cmaxs for both

incubated on ice for 10 min. A fixed amount of 3H-QNB
(3 nM) was then added. Samples were vortexed and
incubated in a shaking water bath at 22 °C for 60 min.
Post-incubation, 2 mL of cold buffer was added to each
sample and the reaction was stopped by filtering samples
under reduced pressure through Whatman GF/B filters
using a Brandel Cell (Brandel Scientific). In vitro AA
results are reported as picomoles of atropine equivalents
per milliliter (pmol/mL). Assay values were standardized
to pmol/mL by multiplying by 5: 1 pmol/0.2
sample = 5 pmol/mL based on the amount of 3H-QNB
displaced by drugs as compared to the atropine standard
curve (Fig. 1). The acceptable assay range is 0.5–
250 pmol/mL, above which results are not reproducible.
Thus, in vitro AA values b0.5 pmol/mL are reported as 0
and values N 250 pmol/mL are reported as N 250 pmol/mL.
All standard curve and drug samples were run in
triplicates. Previously made controls of low and medium
atropine concentrations were run with each assay.
Oxotremorine sesquifumarate (100 μM, Sigma-Aldrich)
was used to assess for nonspecific binding.
younger and older adults were determined based
on nomograms developed from therapeutic drug
monitoring data from 3782 (10% greater than
50 years) patients (Rostami-Hodjegan et al.,
2004). The results of this study are congruent
with the findings of other studies. For this current
report, Cmax was estimated for male and females
separately, given the sex-associated differences in
the pharmacokinetics of clozapine (Table 3). To
be conservative, a positive smoking status was
assumed, given the high prevalence of smoking in
persons with schizophrenia and the demonstrated
decrease in serum clozapine concentrations in
smokers. We estimated trough concentrations for
older adults to be 25% higher than the average
predicted trough concentrations provided in the
nomograms (e.g., the model predicted concentra-
tions to increase 4% every 5 years beyond the
referenced 40 years). The equation C2 = C1 * e−kt
was used to calculate Cmax from trough concen-
trations. The parameters k and t were estimated

2.3. Analysis
Table 4
Estimated Cmax values, based on total daily doses of olanzapine
Atropine standard curve and in vitro AA were cal-
Dose Cmax (ng/mL)
culated using weighted logit–log regression. Values re-
(mg/
ported are averages of two assays, run on separate days. Adult male Adult female Elderly male Elderly female
day)
Concentrations versus in vitro AAs were plotted for each
2.5 5.5 6.1 6.4 7.1
medication. For the medications which demonstrated AA, 5 11 12.2 12.8 14.2
the average peak concentrations (Cmax) at steady-state 10 22 24.4 25.6 28.4
following oral administration of clinically relevant daily 15 33 36.6 38.4 42.6
doses were estimated (see below). Interpolations of the 20 44 48.8 51.2 56.8
30 66 73.2 76.8 85.2
concentration–AA plots were used to determine AAs at a
 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72 67

Fig. 3. Dose–AA relationship for clozapine. * A dose of 800 mg for

Fig. 2. In vitro AA of atypical antipsychotics. In vitro AA for each
atypical antipsychotic concentration was tested in triplicates in two
assays, run on separate days. The error bars represent the standard
deviation of the interassay averages.
elderly females resulted in an in vitro AA over 250 pmol/mL. This
value was outside the acceptable assay range and was therefore not
plotted in the graph.
et al., 2001). Thus, one dose–AA curve was
generated for all ages.

using half-life (t½) and Tmax (time at which Cmax 3. Results

is reached) published values (Clozapine, package
insert 2005). Table 2 presents the typical dose and concentration
(2) Olanzapine: The average olanzapine Cmaxs for both range for each antipsychotic tested. Clozapine, olanza-
younger and older adults were calculated based on pine, and quetiapine all showed a concentration-depen-
data collected from 250 patients (42 [17%] were dent increase in AA (Fig. 2). The highest concentration
older than 59 years) (Gex-Fabry et al., 2003). The of clozapine (1500 ng/mL) resulted in an AA above the
results of this paper approximate findings from other acceptable assay range. Aripiprazole, risperidone, and
studies. Cmax was estimated for male and females ziprasidone did not demonstrate any AA at concentra-
separately, given the sex-associated differences in tions up to 1000 ng/mL (data not shown).
the pharmacokinetics of olanzapine (Table 4). Figs. 3, 4 and 5 show the dose–AA relationship for
Again, a positive smoking status was assumed, clozapine, olanzapine and quetiapine.
given the demonstrated decrease in serum olanza- The average Cmax calculated for each daily dose of
pine concentrations in smokers. We estimated trough clozapine and olanzapine (Tables 3 and 4) was used to link
concentrations for older adults to be approximately
27% higher than trough concentrations for younger
adults based on the values reported by Gex-Fabry
and colleagues (2003). The equation C2 =C1 * e−kt
was used to calculate Cmax from trough concentra-
tions. The parameters k and t were estimated using
t½ and Tmax values reported in the literature
(Callaghan et al., 1999).
(3) Quetiapine: The average quetiapine Cmaxs for both
younger and older adults were calculated based on a
study that reported Cmax at steady-state with admin-
istration of 250 mg, three-times daily (Jaskiw et al.,
2004). Linear pharmacokinetics was assumed in
estimating Cmax at additional doses. There are
changes in quetiapine pharmacokinetics with age.
However, peak plasma concentrations are similar in
younger and older adults (Jaskiw et al., 2004; Wong Fig. 4. Dose–AA relationship for olanzapine.
68 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72
Fig. 5. Dose–AA relationship for quetiapine.
the in vitro concentrations to the daily dose, and sub-
sequently to estimate the relationship between daily dose
and in vitro AA. For example, the average Cmax at 600 mg/
day of clozapine for an adult male is 690 ng/mL. Using
Fig. 2, the in vitro AA for 690 ng/mL of clozapine is
approximately 142 pmol/mL. Thus, the estimated AA for
a patient taking 600 mg/day of clozapine is 142 pmol/mL.
This estimated AA of 142 pmol/mL is then plotted for this
dose of 600 mg/day.
Based on calculated plasma concentrations of each
drug at therapeutic doses, AA was estimated to range
from 27–250, 1–15, and 0–5.4 pmol/mL of atropine
equivalents for clozapine, olanzapine, and quetiapine,
respectively (Figs. 3, 4 and 5). At lower doses of
quetiapine (less than 100 mg/day), AA was estimated to
be 0. At the upper range of daily doses for clozapine and
olanzapine, the estimated AA was higher for older adults
than for younger ones. The highest dose of clozapine
(800 mg/day) resulted in an estimated AA higher than
250 pmol/mL of atropine equivalents, and was therefore
not shown in Fig. 3. For aripiprazole, risperidone, and
ziprasidone, the estimated AA for all therapeutic doses
was 0.
4. Discussion
We developed a model of anticholinergic activity (AA)
for six atypical antipsychotics. With this model, the es-
timated AA for therapeutic doses of aripiprazole, ris-
peridone, and ziprasidone was 0. In contrast, clozapine,
olanzapine, and quetiapine were estimated to have cli-
nically significant dose-dependent increases in AA within
their therapeutic range.
Our model of dose–AA relationship has several
potential limitations. The estimated dose–AA is a way to
assess possible anticholinergic burden. However, the risk
of anticholinergic burden needs to be considered within
the overall clinical history of each patient (e.g., past sen-
sitivity to anticholinergic agents, extrapyramidal symp-
toms, effectiveness of an antipsychotic agent, adherence
concerns). For reasons that are not completely understood,
some individuals receiving a medication with high AA
may not develop clinically apparent anticholinergic ef-
fects, while other patients become confused or even deli-
rious on a drug with more modest AA. Our model does not
allow one to predict which individuals are at greater risk
for anticholinergic toxicity at a given AA level.
In addition, we used average Cmax estimates that do
not take into account inter- or intra-individual variation.
As with most medications, there is a large variability in
plasma or serum concentrations with a given dose of an
atypical antipsychotic due to both environmental and
genetic causes. We were conservative and assumed a
positive smoking status for individuals receiving cloza-
pine or olanzapine. Nonsmokers have on average 48%
and 12% higher serum concentrations at a given dose of
clozapine (Rostami-Hodjegan et al., 2004) and olanza-
pine (Gex-Fabry et al., 2003), respectively.
Both risperidone and ziprasidone were analyzed
using pill forms purchased from our hospital pharmacy.
Impurities or lower concentrations of the drug of interest
might have biased the results. However, our results for
both risperidone and ziprasidone are comparable to what
has been reported previously (see Table 1).
We used rat forebrain and striatum homogenate for the
source of muscarinic receptors. Similar to human fore-
brain and striatum, all 5 muscarinic receptor subtypes are
represented in these brain regions, with M1 and M4 and to
a lesser extent M2 being predominantly expressed (Tice
et al., 1996). Thus, the assay is less sensitive for binding
of medications that may have specificity for M3 or M5.
Furthermore, although there is considerable homology
between human and rodent muscarinic receptors, there
may be a discrepancy in ligand binding between species.
Our assay is designed to optimize the binding of
antagonists (Chew et al., 2005; Mulsant et al., 2003;
Tune and Coyle, 1980). However, in vitro AA may
reflect binding of agonists and thus may not purely be a
measure of AA. Some studies have shown that clozapine
and olanzapine act as partial agonists under specific in
vitro conditions (Bymaster et al., 2003a; Ichikawa et al.,
2002; Richelson and Souder, 2000). However, it is
thought that both of these agents function as antagonists in
vivo (Bymaster et al., 2003a). Thus, we believe that the
values reported here for clozapine and olanzapine re-
present almost exclusively antagonist activity.
Finally, each medication was assessed independently in
an in vitro system. Although we used human serum in each
sample, this in vitro assay may not take into account
possible interaction of medications and endogenous
 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72 69

Table 5
Published studies of in vivo anticholinergic activity in patients with schizophrenia
Study Setting; N Age, Design Mean (S.D.) or Relationship between serum AA and
years: [range] serum cognition or other clinical outcomes
mean AA (atropine
(S.D.) or equivalent)a
range
Chengappa Outpatients; 24 39 Clozapine 27.4 (16.5), No association between AA and MMSE
et al., Olanzapine [4.5–65.5] scores
2000 4.8 (3.0),
Serum AA samples were taken after [1.2–10.6]
morning medication dose
de Leon et Inpatients; 40 Not Clozapine Higher AA associated with constipation
al., 2003 reported 100 mg/day 1.4 (1.1)
300 mg/day 1.9 (1.2)
600 mg/day 2.8 (1.6)
Hitri et al., Inpatients; 15 28–60 Patients receiving typical antipsychotics [0–1.2] AA increased 13-fold following initiation
1987 and amantadine, benztropine, or of benztropine and 2.5-fold following
trihexyphenidyl trihexyphenidyl. No change in AA
Serum AA samples were taken 12 h post following initiation of amantadine
AC drug administration
Katz et al., Outpatients; 22 51 (15) 14 patients receiving AC drugs 3.8 (5.4) Mean MMSE score: 22/30
1985 (12 with No association between AA and verbal
schizophrenia) learning
Perlick et Inpatients; 17 33 Patients receiving neuroleptics; 4 taking 10.6 (8.3), Inverse correlation between AA and
al., 1986 25–49 AC drugs. Serum AA samples taken ≥ 4 [0–28] verbal learning (r = − 0.54, p = 0.01). No
h post medication association between AA and recognition
or nonverbal recall memory
Strauss et Outpatients; 10 31 Patients taking AC drugs for EPS. Patients Of two samples, AA associated with verbal learning scores
al., 1990 21–43 assessed twice, before and after a 2-week higher AA: 3.61
period. Time of medication administration (2.1); lower AA:
not controlled; compliance questionable 1.06 (1.2)
Tracy et Inpatients; 22 45 (8) Clozapine 21.8 (12.0), No association between AA and MMSE
al., 1998 31–58 Risperidone [8.5–46.5] 1.4 scores
Serum AA samples were taken after (1.5), [0–4.0]
morning medication dose
Tracy et Inpatients; 38 40 (10) Clozapine or olanzapine Risperidone 16.0 (13.0) Higher AA associated with impaired
al., 2001 Patients were not taking any other AC 1.0 (1.0) verbal learning and executive control
medication, or medications known to
affect cognition. Serum AA samples were
taken after morning medication dose
Tune and Inpatients (80%) 35 Patients receiving neuroleptic and AC [0–50] Higher serum AA associated with lower
Coyle, and outpatients; 21–65 drugs EPS
1980 35 (31 with
schizophrenia)
Tune and Inpatients (82%) 36 Patients receiving neuroleptic and AC [0–50] Higher serum AA associated with lower
Coyle, and outpatients; 18–81 drugs EPS
1981 109 (95 with
schizophrenia)
Tune et al., Outpatients; 24 36 Patients receiving neuroleptics; 15 taking 12 (2.5), [0–38] Inverse correlation between AA and
1982 20–58 AC drugs. verbal learning (r = − 0.51, p b 0.01)
AA: Anticholinergic activity; AC: Anticholinergic; EPS: Extrapyramidal side-effects; MMSE: Mini-Mental State Examination.
a
Various units have been used to report AA leading to some inconsistencies: Some investigators have used pmol/0.2 mL sample and pmol/mL
interchangeably. Others use a conversion factor of 5 (e.g., 1 pmol/0.2 mL = 5 pmol/mL). Given the uncertainty of some published data, all values in
this Table (with the exception of those from our laboratory), are presented exactly as published in the original reports without regard to units.

substances with muscarinic receptors (Flacker and Lipsitz, an active metabolite of clozapine, is thought to be a mus-
1999). Future studies need to address possible AA of carinic agonist and it may mitigate the anticholinergic
metabolites of the atypical antipsychotics. Norclozapine, effects of clozapine. Hence, when clozapine is taken in
70 M.L. Chew et al. / Schizophrenia Research 88 (2006) 63–72
vivo, the overall anticholinergic effect may be less than
what would be expected based on its relatively high in vitro
AA.
The validity of our model is supported by the cor-
relation between in vitro AA and AA levels measured in
patients taking atypical antipsychotics (Chengappa et al.,
2000; de Leon et al., 2003; Mulsant et al., 2004; Tracy
et al., 2001). Thus, we believe that clinicians can use this
model to estimate the likelihood of clinically relevant
anticholinergic effects.
For older patients, with or without dementia, any AA is
considered detrimental. For instance, Nebes and colleagues
(Nebes et al., 1997) reported that depressed elderly with
detectable serum AA (e.g., greater than 0.25 pmol/mL)
performed more poorly on verbal learning measures, than
did patients with undetectable AA. Mulsant and colleagues
(Mulsant et al., 2003) examined serum AA in community-
dwelling older adults. Individuals with AA greater than
2.7 pmol/mL were 13 times more likely to have an MMSE
score of b 25, as compared with individuals with unde-
tectable AA (adjusting for age, sex, educational level, and
total number of medications). In patients with moderate-to-
severe dementia, Chew and colleagues (Chew et al., 2005)
found an inverse correlation (r= −0.4, p = 0.05) between
serum AA and MMSE scores. It should be noted, that
subjects with higher AA may have a greater medical burden
and thus require larger doses or a more complex medication
regimen. However, in the largest naturalistic study of AA to
date (Mulsant et al., 2003), no association was found
between total number of medications and global cognition
as measured by the MMSE. Overall, of 14 studies in older
persons recently reviewed by Chew and colleagues (Chew
et al., 2005), all but one found an association between AA
and cognitive impairment.
For younger patients, it is not as clear whether any
AA is detrimental or whether there is a threshold AA
over which adverse cognitive effects occur. However,
multiple studies have shown a relationship between AA
and specific areas of cognition known to be impaired by
anticholinergic medications (Table 5). Perlick and col-
leagues (Perlick et al., 1986) and Tune and colleagues
(Tune et al., 1982) independently investigated cognitive
performance in patients with schizophrenia taking con-
ventional antipsychotics. Both reported an inverse cor-
relation (r = −0.5) between serum AA and verbal learning
scores. Tracy and colleagues (Tracy et al., 2001)
examined serum AA and cognitive performance in pa-
tients with schizophrenia taking clozapine, olanzapine, or
risperidone. Higher AA was associated with impairment
in verbal learning and executive control. Using an anti-
cholinergic index (based on published reports of medi-
cation affinity at muscarinic receptors), Minzenberg and
colleagues (Minzenberg et al., 2004) found an association
between anticholinergic load and performance on multi-
ple cognitive tests including verbal learning, visual me-
mory, and praxis. Moreover, anticholinergic load accounted
for approximately 10% of the variance in measures of
specific cognitive tests and was suggested to contribute up
to 30–60% of the memory deficits seen in some patients
with schizophrenia.
In conclusion, these data support that clozapine, olan-
zapine, and quetiapine have a dose–AA relationship,
while aripiprazole, risperidone, and ziprasidone, do not
show AA at any dose within their clinical range. This is
supported by literature findings that clozapine, olanza-
pine, and to a lesser extent quetiapine, are associated with
anticholinergic adverse events (Tracy et al., 2001;
Gardner et al., 2005; Lieberman et al., 2005). Our
model may be a useful tool to determine the dose–AA
relationship of newer atypical antipsychotics and other
psychotropic medications that might have anticholinergic
effects related to their activity at muscarinic receptors.
Acknowledgement
Supported in part by a grant from Janssen Pharma-
ceuticals and by US PHS grants MH067031, MH069430,
and RR00056 from the National Institute of Health. The
authors thank Denise Sorisio for her technical expertise.
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